Surgical system with combined laser ultrasound imaging surgical tool for laser marking and ultrasound imaging

ABSTRACT

In one embodiment of the invention, a robotic surgical system includes a combined laser imaging robotic surgical tool, a control console, and a laser generator/controller. The tool is mounted to a first robotic arm of a patient side cart. The tool has a wristed joint and an end effector coupled together. The end effector has a laser-emitting device to direct a laser beam onto tissue in a surgical site and an image-capturing device to capture images of the tissue in the surgical site. The control console, in communication with the tool, receives the captured images of tissue in the surgical site and displays the captured images on a display device to a user. The laser generator/controller is coupled to the tool and the control console to control the emission of the laser beam onto tissue of the surgical site.

CROSS REFERENCE TO RELATED APPLICATIONS

This non-provisional patent application claims the benefit of and is acontinuation application of U.S. patent application Ser. No. 12/060,112,entitled SURGICAL TOOLS FOR LASER MARKING AND LASER CUTTING filed byMatthew R. Williams et al. on Mar. 31, 2008, now issued as U.S. patentSer. No. 10/368,838.

FIELD

The embodiments of the invention generally relate to robotic surgicalinstruments.

BACKGROUND

Minimally invasive medical techniques are aimed at reducing the amountof extraneous tissue that is damaged during diagnostic or surgicalprocedures, thereby reducing patient recovery time, discomfort, anddeleterious side effects. The average length of a hospital stay for astandard surgery may also be shortened significantly using minimallyinvasive surgical techniques. Thus, an increased adoption of minimallyinvasive techniques could save millions of hospital days, and millionsof dollars annually in hospital residency costs alone. Patient recoverytimes, patient discomfort, surgical side effects, and time away fromwork may also be reduced with minimally invasive surgery.

The most common form of minimally invasive surgery may be endoscopy.Probably the most common form of endoscopy is laparoscopy, which isminimally invasive inspection and surgery inside the abdominal cavity.In standard laparoscopic surgery, a patient's abdomen is insufflatedwith gas, and cannula sleeves are passed through small (approximately ½inch) incisions to provide entry ports for laparoscopic surgicalinstruments. The laparoscopic surgical instruments generally include alaparoscope (for viewing the surgical field) and working tools.

In endoscopic surgery, the working tools are similar to those used inconventional (open) surgery, except that the working end or end effectorof each tool is separated from its handle by an extension tube. As usedherein, the term end effector means the actual working part of thesurgical instrument and can include clamps, graspers, scissors,staplers, and needle holders, for example.

To perform endoscopic surgical procedures, the surgeon passes theseworking tools or instruments through the cannula sleeves to an internalsurgical site and manipulates them from outside the abdomen. The surgeonmay monitor the procedure within the internal surgical site by means ofa laparoscope. Similar endoscopic techniques are employed in, e.g.,arthroscopy, retroperitoneoscopy, pelviscopy, nephroscopy, cystoscopy,cisternoscopy, sinoscopy, hysteroscopy, urethroscopy and the like.

Minimally invasive surgeries are also being performed on other areas ofthe body including the neck and throat regions. The neck and throat is ahighly visible region and scarring is undesirable for aesthetic andhealth privacy reasons, thus a minimally invasive procedure isdesirable. A readily visible thyroid surgical scar may announceunderlying health issues that a patient may not wish disclosed. Due tothe lack of skin folds in the throat and neck region, hiding a surgicalscar may be problematic. In warmer climes, it is preferable to avoidcovering up throat surgery scars with clothing. Operating in a longnarrow enclosed space such as the laryngopharynx is challenging due tospace restrictions and the accessibility of the surgical site. In thesecases, multiple entry ports may not preferred because of visiblescarring and limited space.

BRIEF SUMMARY

The embodiments of the invention are summarized by the claims thatfollow below.

BRIEF DESCRIPTION OF THE DRAWING

FIG. 1A is a block diagram of a robotic surgery system to performminimally invasive robotic surgical procedures with combined laserimaging robotic surgical tools.

FIG. 1B a perspective view of the robotic patient-side system of FIG. 1Awith combined laser imaging robotic surgical tools.

FIG. 1C is a perspective view of the robotic surgical master controlconsole of FIG. 1A, 1D that is used to control the combined laserimaging robotic surgical tools.

FIG. 1D is a block diagram of a robotic surgery system with multiplerobotic surgical master control consoles to control the combined laserimaging robotic surgical tools.

FIGS. 2A-2B illustrate perspective views of exemplary embodiments ofcombined laser ultrasound robotic surgical instruments.

FIG. 3 is a cross sectional view of the tool shaft of the exemplaryembodiments of the combined laser ultrasound robotic surgicalinstruments illustrated in FIGS. 2A-2B illustrating the wires and cablesrouted therein.

FIG. 4 is a magnified side view of the wristed portion of the exemplaryembodiments of combined laser ultrasound robotic surgical instrumentsillustrated in FIGS. 2A-2B.

FIGS. 5A-5C are magnified views of exemplary embodiments of the combinedlaser and ultrasound end effector of the exemplary embodiments of thecombined laser ultrasound robotic surgical instruments illustrated inFIGS. 2A-2B.

FIGS. 6A-6B are magnified cutaway side views of exemplary embodiments ofthe combined laser and ultrasound end effector.

FIGS. 7A-7B are perspective views of a proximal end of exemplary roboticsurgical tools with covers removed to show the cabling and connectorsfor the laser and ultrasound end effectors.

FIG. 8 is a diagram illustrating a combined laser ultrasound roboticsurgical tool laser marking tissue in a surgical site.

FIG. 9 is a diagram illustrating the laser marking on tissue in thesurgical site indicating where a surgeon may perform a minimallyinvasive surgical procedure with one or more robotic surgical tools.

FIG. 10 is a perspective view of a portion of a robotic patient-sidesystem with a combined laser imaging robotic surgical tool for minimallyinvasive surgery through a single port.

FIG. 11 is another perspective view of the portion of the roboticpatient-side system of FIG. 10 with the combined laser imaging roboticsurgical tool.

FIG. 12 is a perspective view of a distal end portion of the roboticpatient-side system of FIG. 10 with the combined laser imaging roboticsurgical tool.

FIG. 13 is a perspective view of the combined laser imaging roboticsurgical tool for use with the robotic patient side system of FIG. 11.

FIGS. 14A-14B are cutaway side views of embodiments of the end effectorof the combined laser imaging robotic surgical tool.

FIGS. 15A-15B are bottom views of the embodiments of the end effector ofFIGS. 14A-14B, respectively.

Similar reference numbers in the different drawings are associated withthe same or similar elements but may have a different configuration.

DETAILED DESCRIPTION

This detailed description describes exemplary implementations that areillustrative of the invention, and so is explanatory and not limiting.The invention is limited only by patented claims. In the drawings, someelements have been omitted to more clearly show the embodiments of theinvention.

Introduction

The embodiments of the invention include an apparatus and system ofrobotic surgical instruments or tools used in robotic surgical systemswith multiple capabilities. The robotic surgical tools include thecapability to deliver laser energy for use in marking, cutting, orcauterizing tissue. A video camera, an ultrasound probe, or otherimaging device is included with the robotic surgical tool to display anarea of tissue in a surgical site where the laser energy may bedelivered.

An end effector including both the laser and imaging device, areconnected to a wristed joint capable of multiple degrees of freedom ofmovement. The wristed joint may use disks or vertebrae and actuationcables or tendons to allow a surgeon to remotely manipulate the endeffector within small tight enclosures with a high degree of precisionfrom a master control workstation or console. An exemplary wristed jointis described in detail in U.S. Pat. No. 6,817,974 entitled SURGICAL TOOLHAVING POSITIVELY POSITIONABLE TENDON-ACTUATED MULTI-DISK WRIST JOINTfiled by Thomas G. Cooper et al. on Jun. 28, 2002 which is incorporatedherein by reference.

One imaging device described in the embodiments of the invention may usean ultrasound probe to capture images of the surgical site.Ultrasonography utilizes sound waves emitted from transducers to formimages. During transmit mode, acoustic energy is created by sendingelectrical signal to the transducer causing the elements of thetransducer to resonate. The acoustic signal produced travel to nearbystructures where some of the signal is absorbed and some reflected backto the transducer. In receive mode, the reverse occurs, i.e. reflectedacoustic signals causes the transducer to resonate producing measurableelectrical signals which can be processed into images.

The images produced by ultrasound may contain details not available totraditional laparoscopes using a light viewing scope. For example,ultrasound images may differentiate between healthy and cancerous cellsbased on a difference in acoustic impendence. Malignant lesions inthyroid and breast cancers are harder and stiffer than benign lesionsand thus have a higher acoustic impendence that may be detectable by atrained physician or ultrasound technician.

Another image device described in the embodiments of the invention arevideo cameras to capture video images of the surgical site. A videocamera captures images in the visible spectrum and uses a light sourceto illuminate the surface of tissue in a surgical site. A digital videocamera with a charge-coupled device (CCD) may be used to capture digitalvideo images of a surgical site. A bundle of optical fibers may be usedas light pipes to direct a light source at one end down into thesurgical site to provide the illumination to capture the digital videoimages. The video images captured by the camera may be transmitted toone or more viewing monitors that a surgeon uses to visualize theinternal anatomy and guide any surgical procedures.

Note that while ultrasound imaging and video imaging are disclosedherein, other forms of imaging technology, such as X-ray, magneticresonance, computed tomography, visible, infrared, and ultravioletimaging, may also be used to display the surgical site depending on theneeds of the surgeon.

Robotic Surgical System for Ultrasound Imaging and Laser Cutting

Referring for a moment to FIG. 1A, a robotic surgical system 100A isillustrated for performing ultrasound imaging and laser cutting/ablationduring minimally invasive robotic assisted surgery. The robotic surgicalsystem 100A includes one or more control workstations or surgeon'sconsoles 150A, a patient side manipulator or patient side cart 152, andone or more robotic surgical instruments or tools 101A-101D (generallyreferred to by reference number 101) coupled to the patient side cartvia robotic surgical arms 153 and set up arms 156. The set up arms 156are passive arms that are fixed into an initial position to support therobotic surgical arms. The robotic surgical arms 153 may be moved undercommands from the surgeon's console to manipulate the positions of thetools 101A-101D and perform minimally invasive robotic assisted surgery.

The robotic surgical tools 101 may include such end effectors as clamps,graspers, scissors, staplers, needle holders, cameras, ultrasoundimagers, and laser ablation/cutting/marking. The robotic surgical tools101 may combine a plurality of capabilities into one tool and endeffector. For example, the robotic surgical tool 101A may combine anultrasound imaging and a laser marking capability together into onetool. As another example, the robotic surgical tool 101B may include oneor more video cameras and a laser ablation/cutting capability combinedinto one tool. The robotic surgical tools 101C-101D may be tissuemanipulation tools such as to grasp, cut, or suture tissue together, forexample.

The robotic surgical tools 101 may be mounted to and dismounted from therobotic surgical arms 153 of the patient side cart 152. The patient sidecart 152 is in turn coupled to the surgeon's console 150A. Commands fromthe surgeon's console 150A are coupled to the patient side cart 152 togenerally control the robotic surgical tools 101. The robotic surgicaltools 101 may send signals back to the surgeon's console 150A such thatcommands from the workstation 150A may be transmitted to the cart 152.To perform robotic assisted surgeries, the patient side cart 152 ispositioned adjacent to a patient P as illustrated in FIG. 1A.

The robotic surgical system 100A further includes one or more lasergenerator/controllers 102A-102B and an ultrasound generator/controller102C to couple to the robotic surgical tools 101A-101B to performultrasound imaging and laser cutting/ablation during minimally invasiverobotic assisted surgery. The laser generator/controller 102A is coupledto the robotic surgical tool 101A by a cable 106. The ultrasoundgenerator/controller 102C is coupled to the robotic surgical tool 101Aby a cable 108. The laser generator/controller 102B is coupled to therobotic surgical tool 101B by a cable 107. To control the ultrasoundimaging and laser cutting/ablation during minimally invasive roboticassisted surgery, the one or more laser generator/controllers 102A-102Band the ultrasound generator/controller 102C are coupled to a computer151A in the surgeon's console 150A. The laser generator/controllers102A-102B are respectively coupled to the computer 151A in the surgeon'sconsole 150A by cables 109A-109B. The ultrasound generator/controller102C is coupled to the computer 151A in the surgeon's console 150A by acable 109C.

The power levels and wavelengths of the laser light generated by thelaser generator/controllers and/or laser diodes to laser ablate/cut bodytissue may vary. For example, typical power level ranges for laserablation/cutting are (i) three to six (3-6) watt range for fine tissuedissection, not particularly wavelength dependent; (ii) ten to fifteen(10-15) watt range for larger dissections with approximately two micronwavelength; (iii) twenty-five to sixty (25-60) watt range withapproximately 532 nano-meters (nm) (green light) wavelength; and (iv) upto sixty (60) watt for carbon dioxide (CO2) laser (approximately ten andsix tenths (10.6) micron wavelength). If the laser is to be used formarking tissue, the power level may be less, such as around one wattwith approximately a two-micron wavelength.

Referring now to FIG. 1B, the patient side cart 152 includes a pluralityof robotic arms 153 to which the robotic surgical tools 101A-101C areremoveably coupled. The interface between the robotic surgical tools101A-101C and the robotic surgical arms 153 is the same (e.g.,standardized) so that the tools are interchangeable. The movement of therobotic surgical arms 153 may be adapted to manipulate interchangeablesurgical instruments, such as laser surgical tools, optical sensors,acoustic sensors, patient telemetry sensors as the need arises. Eachrobotic surgical arm 153 may include a sled 177 with drive mechanisms tocontrol the position of the robotic surgical tools and the associatedend effectors, if any. The sled 177 may be moved along an insertion axisparallel to the shaft of the tool as indicated by the double-headedarrow 179.

Referring now to FIG. 1C, a perspective view of the robotic surgicalmaster control console 150 is illustrated. The master control console150 of the robotic surgical system 100 may include the computer 151, abinocular or stereo viewer 192, an arm support 194, a pair of controlinputs (control input wrists and control input arms) 160 in a workspace196, foot pedals 198 (including foot pedals 198A-198B), and a viewingsensor 193. The master control console 150 may also be referred to as asurgeon's console or workstation.

The master control console 150 provides substantial dexterity to asurgeon while working within an internal surgical site. The mastercontrol console 150 controls the motion of the servo-mechanicallyoperated robotic surgical instruments 101. During the surgicalprocedure, the telesurgical system can provide mechanical actuation andcontrol of a variety of robotic surgical instruments or tools 101 havingend effectors, such as tissue graspers, needle drivers, or the like. Therobotic surgical instruments or tools 101 perform various functions forthe surgeon, such as holding or driving a needle, grasping a bloodvessel, or dissecting tissue, or the like, in response to manipulationof the master control devices 160.

The master control console 150 allows one or more surgeons to remotelyoperate on a patient by providing images of the surgical site at themaster control console 150. The stereo viewer 192 has two displays wherestereo three-dimensional images of the surgical site may be viewed toperform minimally invasive surgery. When using the master controlconsole, the operator O typically sits in a chair, moves his or her headinto alignment with the stereo viewer 192 to view the three-dimensionalimages of the surgical site. To ensure that the operator is viewing thesurgical site when controlling the robotic surgical tools 101, themaster control console 150 may include the viewing sensor 193 disposedadjacent the binocular display 192. When the system operator aligns hisor her eyes with the binocular eyepieces of the display 192 to view astereoscopic image of the surgical worksite, the operator's head setsoff the viewing sensor 193 to enable the control of the robotic surgicaltools 101. When the operator's head is removed the area of the display192, the viewing sensor 193 can disable or stop generating new controlsignals in response to movements of the touch sensitive handles in orderto hold the state of the robotic surgical tools. While viewing athree-dimensional image of the surgical site on the stereo view 192, thesurgeon performs the surgical procedures on the patient by manipulatingthe master input devices of the workstation.

The arm support 194 can be used to rest the elbows or forearms of theoperator O (typically a surgeon) while gripping touch sensitive handlesof the control input 160, one in each hand, in the workspace 196 togenerate control signals. The touch sensitive handles 160 are positionedin the workspace 196 disposed beyond the arm support 194 and below theviewer 192. This allows the touch sensitive handles to be moved easilyin the control space 196 in both position and orientation to generatecontrol signals. Additionally, the operator O can use his feet tocontrol the foot-pedals 198 to change the configuration of the surgicalsystem and generate additional control signals to control the roboticsurgical instruments.

The computer 151 may include one or microprocessors 182 to executeinstructions and a storage device 184 to store software with executableinstructions that may be used to generate control signals to control therobotic surgical system 100. The computer 151 with its microprocessors182 interprets movements and actuation of the touch sensitive handles(and other inputs from the operator O or other personnel) to generatecontrol signals to control the robotic surgical instruments 101 in thesurgical worksite. In one embodiment of the invention, the computer 151and the stereo viewer 192 map the surgical worksite into the controllerworkspace 196 so that it feels and appears to the operator O that thetouch sensitive handles 160 are working over the surgical worksite.

The robotic surgical instruments 101A-101B on the robotic arms 158A-158Btypically include elongated shafts, with proximal and distal ends. Endeffectors are generally mounted on wrist-like mechanisms pivotallymounted on the distal ends of the shafts, for enabling the instrumentsto perform one or more surgical tasks. Generally, the elongated shaftsof surgical instruments allow the end effectors to be inserted throughentry ports in a patient's body to access the internal surgical site.Movement of the end effectors is generally controlled via mastercontrols on the control console 150.

Further information regarding robotic surgical systems may be found forexample in U.S. Pat. No. 6,331,181, entitled SURGICAL ROBOTIC TOOLS,DATA ARCHITECTURE, AND USE, issued to Tierney et al on Dec. 18, 2001,which is incorporated by reference.

Robotic Surgical System with Remote Workstation

Referring for the moment to FIG. 1D, a robotic surgical system 100D isillustrated for performing ultrasound imaging and/or lasermarking/cutting/ablation during minimally invasive robotic assistedsurgery. The robotic surgical system 100D differs from the roboticsurgical system 100A in that a second surgeon's console 150B may also beused to control the robotic surgical tools 101 and receive signalsthere-from. The second workstation 150B allows another user (e.g., asecond surgeon) to assist in robotic assisted surgical procedures onpatients, such as if there are multiple tools being used and extra handsare needed to control those robotic surgical tools.

For example, the second surgeon's console 150B may be used to controlthe robotic surgical tool 101A that combines an ultrasound imaging and alaser marking capability together into one tool. A second surgeon ormentor at the second surgeon's console 150B may view ultrasound imagesand laser mark corresponding tissue in a body cavity for viewing by thefirst surgeon at the first surgeon's console 150A. Alternatively, thesecond surgeon at the second surgeon's console 150B may operate a laserin an end effector of a robotic surgical tool to cut or ablate tissue ina body while the first surgeon is operating other tools with his twohands.

The second surgeon's console 150B may be located remotely a distanceaway from the first surgeon's console 150A. The remote workstation 150Bmay be situated in another part of the medical facility or may befurther removed and part of a greater network of remote workstations. Inthis case, second surgeon's console 150B may be connected as part of thesurgical system through one or more communication links 165A-165B to theworkstation 150A, the cart 152, and/or the generator/controllers102A-102C.

The remote workstation 150B may be capable of indirect control of therobotic surgical tools 101 and their generator/controllers 102A-102Cthrough the computer 151A of the workstation 150A. Optionally the remoteworkstation 150B may directly control the robotic surgical tools 101 andtheir respective generator/controllers 102A-102C.

Remote workstation 150B may have the same controls as workstation 150Aincluding controls 160 for movement of a robotic surgical tool with anultrasound probe and a display 192 to view images from one or morecameras and the ultrasound probe. Other controls on the surgeon console150A and the remote workstation 150B may allow the surgeon to operate arobotic surgical tool with a laser-emitting device. The laser generatormay be triggered, focused, and/or selectively powered (increase ordecrease the power of the laser emitted) by using the controls on theworkstation 150A or the controls of the extra workstation 150B.

For example, the robotic surgical tools 101A-101B may be combinedlaser-endoscopic cameras each having a camera and a laser-emittingdevice. Video images may be captured by the pair of cameras in thecombined laser-endoscopic camera tools 101A-101B and coupled to thesystem via the video cables 170A-170B. Both sets of video imagescaptured by the pair of cameras may be displayed at both surgeonconsoles 150A-150B by the stereo viewer 192 of each and at the remote orassistant display 154. The laser functionality of the combinedlaser-endoscopic camera tools 101A-101B may be used as a laser-pointingdevice with a lower power laser light. The laser generator may be set tolow power or the combined laser-endoscopic camera tool 101A-101B mayinclude a low power laser diode. The mentoring surgeon M at the remoteworkstation 150B may control the combined laser-endoscopic camera tool101A to point out anatomy in the patient P to the surgeon O at the localworkstation 150A and those (e.g., assistant A or medical students in aremote location) watching the display 154. The operating surgeon O atthe local workstation 150A may control the combined laser-endoscopiccamera tool 101B to point out anatomy in the patient P to the surgeon Mat the remote workstation 150A and those (e.g., assistant A or medicalstudents in a remote location) watching the display 154. In this mannerwith both the operating surgeon O and the mentoring surgeon M, the mayeach use laser pointer devices provided by the combined laser-cameratools to discuss anatomy, such as for mentoring or proctoring.

Further information regarding a remote workstation for robotic surgicalsystems is found in U.S. patent application Ser. No. 11/322,866,entitled STEREO TELESTRATION FOR ROBOTIC SURGERY, filed by Ben Hambrechtet al. on Dec. 30, 2005, which is incorporated by reference.

Robotically Controlled Ultrasound Imaging and Laser Tool

Referring now to FIG. 2A, a perspective view of a combinedlaser-ultrasound robotic surgical tool 200A is illustrated. The combinedlaser-ultrasound robotic surgical tool 200A has multiple capabilities toprovide ultrasound imaging and laser cutting/marking.

The combined laser-ultrasound robotic surgical tool 200A includes amountable housing 201A, a system cable 208, a laser cable 106, a lasercable connector 210A, an ultrasound cable 108, an ultrasound cableconnector 212; a hollow rotatable cylindrical shaft 214, a wristed joint218, and a combined laser-ultrasound end effector 220 coupled togetheras shown in FIG. 2A. With the combined laser-ultrasound end effector 220coupled to the wristed joint 218, the end effector 220 can be moved overmultiple degrees of freedom in response to a surgeons input from theconsole 150A, 150B.

The mountable housing 201A includes a mountable base 204 and a housingcover 202 coupled to the base. The mountable base 204 can be mounted toand dismounted from the sled 177 (see FIG. 1B) to couple and decouplethe tool 200 to/from the robotic surgical arm. This allows the tool tobe quickly changed to another type of tool during surgery. Additionally,it allows the tool to be changed out for maintenance or sterilizationafter surgery. The mountable housing 201A includes rotatable receivers(e.g., see rotatable receivers 1310 in FIG. 13) extending from the base204 to interface to rotatable drivers (e.g., see rotatable driver 1122in FIG. 11) of the sled 177 and a robotic surgical arm. The rotatablereceivers receive a torque to rotate the shaft 214 and to control thewristed joint 218 to move the end effector 220. Actuators coupled to thebase 204 receive the torque and translate it like a transmission toactuating cables 216 to control the wristed joint 218 and move the endeffector 220.

The system cable 208 coupled to the tool 200 exiting from the mountablehousing 201A includes the ultrasound cable 108 and the laser cable 106.The ultrasound cable 108 further includes a plurality of ultrasoundsignal wires 304. The laser cable 106 may include an optical fiber forcarrying laser light from a laser generator/controller (e.g., see lasergenerator/controllers 102A, 102B illustrated in FIG. 1B) through thetool 200 to exit out through an aperture in the end effector 220.Alternatively, the laser cable 106 may include signal wires and/or powerwires to power and control a laser diode to generate the laser light inthe tool 200 for exit from the aperture in the end effector 220. Thelaser cable connector 210A is connected to an end of the laser cable 106to couple an end of an optical fiber or alternatively wires therein to alaser generator/controller (e.g., see laser generator/controllers 102A,102B illustrated in FIG. 1B).

In the case of an optical fiber within the cable 106, the lasergenerator/controller provides the laser light of the desired wavelengthand power that is coupled into the optical fiber. In the case of wireswithin the cable 106, the laser generator/controller provides power,ground, and control signals to control a laser diode within the toolthat generates the laser light of the desired wavelength and power. Ineither case, the laser generator/controller is controlled by a surgeonor user at a control console 150A, 150B to generate the laser light whendesired with the desired wavelength and range of power.

The ultrasound cable connector 212 is connected to an end of theultrasound cable 108 to couple its ultrasound signal wires 304 to anultrasound generator/controller (see ultrasound generator/controller102C illustrated in FIG. 1B). An opposite end of the signal wires 304 inthe cable 108 may couple to the ultrasound transducer elements (seeultrasound transducer elements 504 illustrated in FIGS. 5A-C) in the endeffector 220. Alternatively, the opposite end of the signal wires 304may couple to circuits to combine signals together for routing throughthe tool down the shaft 214 to and from the ultrasound transducerelements.

The ultrasound controller/generator 102C provides a drive signal toultrasound transducers in the end effector 220 to cause them to emitultrasonic energy. The ultrasound transducers in the end effector 220further receive reflected ultrasound waves and converts them intoelectrical signals that are coupled back to the ultrasoundgenerator/controller 102C for processing of the return signals receivedby the transducers. The ultrasound controller/generator 102C may formultrasound images out of the return signals and provide video imagesover the cable 109C for display to the surgeon at the console 150A,150B. An ultrasound controller/generator 102C and the ultrasoundconnector 212 are described in detail in U.S. Pat. No. 5,630,419entitled SEALING CONNECTOR FOR MULTICONDUCTOR CABLES issued toRanalletta, Joseph V on May 20, 1997, which is incorporated herein byreference.

The mountable housing 201A is the interface of the tool with a roboticsurgical system such as the DaVinci Surgical System by IntuitiveSurgical. Amongst other things, the mountable housing 201A includes thedrive mechanisms or transmission under a cover 201A to move drive cables216 which in turn move the wristed joint 218. An embodiment of thewristed joint or wrist member 218 is better illustrated by FIG. 4. Themountable housing 201A may further include an isolation chamber 203Aunder the cover to isolate electrical connections and cables from thedrive mechanisms or transmission for the drive cables 216.

A proximal end of the hollow cylindrical shaft 214 is pivotally coupledto the base 204 of the mountable housing 201A. A proximal end of thewristed joint 218 is coupled to the distal end of the shaft 214. The endeffector 220 is coupled to a distal end of the wristed joint 218. Notethat the shaft 214, the joint 218, and the end effector 220 may rotatetogether to provide an additional freedom of movement for the endeffector. The shaft 214 is a hollow cylindrical tube that extends thereach of combined laser-ultrasound end effector 220.

The drive cables 216 are routed within the shaft 214 and may extend overits length from the base 204 to the wristed joint 218, or extend furtherto an end effector. The drive cables 216 are typically arranged withinthe shaft to move nearer its inner surface away from a center axis ofthe shaft 214 as shown in FIG. 3. This provides sufficient area to routea cable bundle 300, including ultrasound signal cables 304 and a lasercable 302.

Referring now to FIG. 3, a cross section of the tool shaft 214 isillustrated to show a cable bundle 300 and drive cables 216 routed inthe shaft. The cable bundle 300 is coaxially positioned near a centeraxis of the tool shaft 214, and is routed through the tool shaft 214,the wristed joint 218, and into the end effector 220. The cable bundle300 includes a laser cable 302, ultrasound cables 304 around the lasercable 302, and a sheath 306 around the laser cable 302 and theultrasound cables 304.

The drive cables 216 that are routed through the shaft 214 are spacedapart from the cable bundle 300 and positioned near the innercircumference of the shaft 214. As the drive cables 216 may move alongthe shaft 214, they are spaced apart from the bundle 300 to try to avoidwear. The drive cables 216 may also be spaced from each other near theinner circumference of the shaft 214 as shown. The wristed joint 218,shaft 214, and end effector 202 may include cable guides at their innerperiphery to align and retain the position of the drive cables 216.Retaining the drive cables 216 on the periphery allows end effectoractuation cables (if any), electrical cables, ultrasound signal wires,and optical cables, to be routed down the center or lumen of shaft 214and wristed joint 218 with less interference.

The laser cable 302 may be in the center of the cable bundle 300,coaxially positioned near a center axis of the tool shaft 214, and runthe length of the tool from the housing 201A at a proximal end to nearan aperture in the end effector 220 at the distal end. In anotherembodiment of the invention, the laser cable 302 may further extend outfrom the proximal end of the tool 200A and into the laser cable 106 tocouple to the laser generator/controller 102A, 102B. In one embodimentof the invention, the laser cable 302 is a fiber optic cable, lightpipe, or optical fiber to propagate the laser energy generated by alaser diode (e.g., laser diode 708 in FIG. 7A) or the lasercontroller/generator 102C through the tool 200A, 200B to exit from anaperture in the end effector 220. In another embodiment of theinvention, the laser cable 302 is one or more electrical cables to powerand control a laser diode (e.g., laser diode 608 in FIG. 6B) in the endeffector 220 so that the laser energy is locally generated by the tool.

The ultrasound signal wires 304 in the bundle 300 near the laser cable302 are numerous. The number of ultrasound signal wires 304 and relativesize of the cables shown in FIG. 3 are for illustration purposes only.The actual number of ultrasound signal wires 304 within the cable bundle300 depends upon the capabilities of the ultrasound probe and the numberof ultrasound transducer elements. The greater the number of ultrasoundtransducer elements, the greater is the number of ultrasound signalwires 304 routed in the cable bundle 300. The ultrasound signal wires304 are insulated electrical cables for driving signals to excite theultrasound transducer elements to generate the ultrasound waves and forreceiving return signals back from the ultrasound transducer elementsfor coupling to an ultrasound controller/generator for signalprocessing.

In one embodiment of the invention, the ultrasound transducer 500includes one hundred twenty eight (128) ultrasound transducer elements504 arranged along the length of the ultrasound probe 500. The acousticwindow 510 may be one (1) transducer element wide andone-hundred-twenty-eight (128) transducer elements in length. In thiscase, the 128 transducers elements require 128 cables with two wires ineach to drive them or more specifically, 256 conductors. Each transducerelement typically has a pair of wires, a signal wire and a ground wire.The signal wire is for both transmitting and receiving ultrasoundsignals.

The sheath 306 is provided around the laser cable 302 and the ultrasoundcables 304 to protect and bundle them together. The cable sheath 306 maycomprise one or more segments of different material depending upon thelocation of the cable bundle within the tool. The one or more segmentsof the cable sheath 306 may be made of a flexible material or a rigidmaterial. For example, the segment of the cable sheath 306 in the toolshaft 214 may be a rigid insulating plastic if the tool shaft itself isrigid. In contrast, the segment of the cable sheath 306 in the wristedjoint is a flexible material. Otherwise, a rigid sheath may limit themovement of the end effector 202. One of the purposes of the cablesheath 306 is to protect the ultrasound signal wires 304 and the lasercable 302 from contact with the drive cables 216. Although the drivecables 216 may be routed through guide holes, slackening and tensioningof the drive cables 216, as well as movement of the bundle 300, mayresult in inadvertent contact of the sheath 306 with the drive cables.

The cable sheath 306 may also facilitate the removal and replacement ofthe laser cable 302 contained therein. The cable sheath 306 mayfacilitate catherizing the laser cable 302 so that it may be removed andreplaced in case of a malfunction. The cable sheath 306 may provide aguide for threading the laser cable 302 through the tool shaft 214 andthe wristed joint 218 with minimal interference from the drive cables216.

Referring now to FIG. 4, the cable bundle 300 is routed through thewristed joint 218 to the end effector 220. The wristed joint seeks toemulate the dexterity of a surgeon's wrist in the tool 200A, 200B. Thewristed joint 218 is used to manipulate the position of the combinedlaser imaging end effector 202 over at least two degrees of freedom.Other end effectors or working elements may be combined together andcoupled to the wristed joint to perform robotic assisted surgery such asscissors, graspers, scalpels, or imaging devices such as high definitionoptical cameras and ultrasound probes. A wide range of motion in thewristed joint 218 is especially advantageous in a small surgical site toposition the end effector 220 therein.

In one embodiment of the invention, the wristed joint 218 is a segmentedwrist joint and includes a plurality of hollow disks or vertebrae402-420 stacked or coupled in a series between the end effector 202 andthe shaft 214. A proximal vertebra 410 is coupled to the shaft 214. Adistal vertebra 402 couples to and supports the end effector 202. Thedistal vertebra 402 may serve as a mounting base for various kinds ofsingle-element and multi-element end effectors, such as scalpels,forceps, scissors, cautery tools, retractors, and the like. There is atleast one intermediate or medial vertebra 404-408 disposed between theproximal vertebra 410 and the distal vertebra 402 to provide at leasttwo degrees of freedom. Each disk or vertebrae 402-410 is configured torotate in at least one degree of freedom with respect to eachneighboring disk. In one embodiment of the wristed joint, a pair of tabsor segments 414 on opposite sides of the distal vertebra 402 and theintermediate vertebra 404-408 pivotally interface with a pair of slots416 on opposite sides of the intermediate vertebra 404-408 and theproximal vertebra 410 for the wristed joint to pivot in a controlledmanner.

A central lumen internal to the hollow disks or vertebrae 402-420 mayserve as a conduit for fluid conduits (e.g., laser cooling, gas blower,irrigation, or suction), and the cable bundle 300.

The plurality of drive cables 216 routed in the shaft 214 extend intothe wristed joint 218. The drive cables 216 may be one or more cableloops. One or more drive cables 216 may extend through the wristed joint218 and into the end effector to actuate working elements. A distalportion of the drive cables 216 actuating the wristed joint 218, aregenerally coupled to one or more of the plurality of hollow disks orvertebrae 402-420 to pivotally actuate the connected vertebra. Aproximal portion of the drive cables 216 ends within the mountablehousing 201A, 201B of the tool 200A, 200B. The proximal portion of drivecables 412 actuating the wristed joint 218 may generally be coupled todrive mechanisms within the mountable housing 201A. The drive mechanismswithin the mountable housing are configured to controllably move atleast selected ones of the plurality of drive cables 216 to pivotallyactuate the plurality of connected vertebrae 402-410 to bend the wristmember with respect to the shaft.

This and alternate embodiments of a segmented wrist joint for thewristed joint 218 are more fully described in U.S. Pat. No. 6,817,974entitled SURGICAL TOOL HAVING POSITIVELY POSITIONABLE TENDON-ACTUATEDMULTI-DISK WRIST JOINT filed by Thomas G. Cooper et al. on Jun. 28,2002, which is incorporated herein by reference.

Referring now to FIGS. 3 and 4, the cable bundle 300 is routed throughthe wristed joint 218 to the end effector 220. The cable bundle 300 ispositioned towards the center portion of the wristed joint 218 to avoidthe vertebrae and drive cables 216 and to minimize bending of the cablebundle 300 therein. The cable sheath 306 of the cable bundle 300 furtherprotects the ultrasound cables 304 and the laser cable 302 from thevertebrae of the wristed joint and the drive cables.

It may be preferable to retain the laser cable 302 near the center ofthe bundle 300. In one embodiment of the invention, the laser cable 302is an optical fiber. The placement of the cable bundle 300 near thecenter of wristed joint 218 may limit damage to an optical fiber byinsulating it in several layers of cables 304 and the sheath 306. If anoptical fiber is overly bent greater than a predetermined angle, theoptical signal within the cable may refract and escape through the fibercladding thereby lowering the laser energy that may be propagatedtherein. Excessive bending may also permanently damage an optical fiberby causing micro cracks therein that may compromise light transmission.This may result is bend loss in an optical fiber such that there is aloss of signal strength from one end of the fiber to the other. Thecenter of the shaft and wristed joint may experience less bending thanthe periphery. Thus, placement of the laser cable 302 near the center ofthe cable bundle may subject an optical fiber to less bending relativeto the outer circumference of the wristed joint 218. Retaining theoptical fiber near the center of the wristed joint and cable bundle 300insulated by the outer layers of cables, wires, and sheathingsurrounding it, may help limit the bending and shock an optical fibermay experience. To ease replacement in the case of damage, the lasercable 302 may have its own sheath or conduit 303 into which the cablemay be removed and inserted for replacement purposes.

Referring now to FIGS. 5A-5C, views of alternate embodiments 220A-220Cof the combined laser ultrasound imaging end effector 220 areillustrated. Each of the embodiments of the combined laser ultrasoundimaging end effectors 220A-220C includes an ultrasound probe 500 toprovide ultrasound images and facilitate laser marking/cutting by laser.Each of the end effectors 220A-220C couples to the wristed joint 218 andincludes a case, housing, or enclosure 502; a plurality of ultrasoundtransducer elements 504 forming the ultrasound probe 500; and an openingor aperture 506 from which laser light may exit for marking or cutting.The laser cable 302 from the wristed joint 218 is routed towards thelaser aperture 506 in each. The ultrasound cables 304 from the wristedjoint 218 are routed and coupled to some of the plurality of ultrasoundtransducer elements 504 of the ultrasound probe 500.

The laser aperture 506 may be located in different positions asillustrated by the embodiments of the combined laser ultrasound imagingend effectors 220A-220C of FIGS. 5A-5C, respectively, so as to minimizeinterference with the ultrasound acoustics of the ultrasound transducerelements 504. For example, in FIG. 5A, the laser aperture 506 islongitudinally positioned near a mid region of the ultrasound probe 500and the edge of the enclosure 502 so as to avoid a break in theultrasound transducer elements. In FIG. 5B, the laser aperture 506 ispositioned near a distal end of the ultrasound probe 500 and a center ofthe enclosure 502. In FIG. 5C, the laser aperture 506 is positioned neara proximal end of the ultrasound probe 500 and a center of the enclosure502.

The enclosure 502 is a protective case surrounding the plurality ofultrasound transducer elements 504 of the ultrasound probe 500. Theenclosure 502 may be hermetically sealed so that body fluids such asgastric juices, blood, bile, etc. are not trapped in its interior. Thisis so the tool 200A, 200B may be readily sterilized for repeated use indifferent robotically assisted surgeries of different patients. Theenclosure 502 can also protect the ultrasound probe 500 duringsterilization procedures.

The enclosure 502 is typically formed of an acoustically appropriatematerial to provide an acoustic lens or window 510 for the ultrasoundtransducer elements 504 of the ultrasound probe 500. A separate acousticlens or window 510 over the ultrasound transducer elements 504 may behermetically sealed to the housing. In which case, the enclosure 502 maybe made of a different material that is not as accoustically appropriateas the window 510. In one embodiment of the invention, the non-acousticportions of the housing or enclosure 502 are formed of ULTEM 1000polyetherimide (generally, an amorphous polymer or plastic) made byGeneral Electric Company, for example, while the acoustic lens or window510 is formed out of an acoustically acceptable material, such as asilicone room temperature vulcanizing (RTV) compound made byDow-Corning, for example. Alternatively, the entire housing or enclosure502 may be made of the same material as the acoustic lens or window 510.For injection molding of the casing and lens as one-piece, it may bedesirable to cast the entire enclosure 502 out of silicone roomtemperature vulcanizing (RTV) compound. When using a casing materialhaving non-acoustic properties, the ultrasound lens or window 510 can beformed separately from other suitable acoustic materials, such aspolyurethanes for example.

The internal structure of the enclosure 502 may be formed of a rigidmaterial. Because autoclaving is an often useddisinfecting/sterilization method the deformation temperature of theinternal structures should also exceed the 249 degrees Fahrenheit oftypical autoclave procedures. By way of example, metals such asaluminum, stainless steel, brass, or even structural plastic may beused. The internal structure of the enclosure 502 may have receptaclesto receive the array of ultrasound tranducers 504, as well as channelsin which the laser cable 302 and ultrasound signal wires 304 may berouted from the wristed joint 218.

The ultrasound probe 500 transmits acoustic energy into body tissuewithin a surgical site and converts the return signal into an electricalsignal. The ultrasound transducer elements 504 of the ultrasound probe500 transmit an acoustic signal into the body tissue of a patient. Thesignal bends when it encounters the interfaces between differentstructures, i.e. when it encounters material with a different acousticimpendence, and is reflected back. The reflected signal is received bythe ultrasound transducer elements 504 and processed into an image ofthe surgical site.

The intensity of the return signal and the time it takes to receive thesignal may be plotted by a computer processor to produce a twodimensional image of the area scanned by the ultrasound probe 500.Generally the closer the probe 500 is to the tissue or organ beingscanned, the better the resolution of the ultrasound image. To producethree-dimensional images with the ultrasound probe 500, multiple arraysof transducers 504 are used or alternatively the probe 500 may berotated or moved around to scan tissue or organs from differentpositions to generate multiple images. The multiple images may then becombined together and interpolated by computer software to displaythree-dimensional images.

The transducer elements 504 comprise piezoelectric ceramic elements. Inorder to resonate the piezoelectric ceramic element and receive a returnsignal, each is electrically connected to a signal source and ground.The transducer elements 504 may be arranged into a one-dimensional arrayor a multi-dimensional array.

The series of piezoelectric ceramic elements, which make up transducerelements 504, may be formed out of a single piece of ceramic material. Abreak in the series of transducer elements 504 to incorporate the laseraperture 506 may be impractical. Furthermore, a laser aperture 506placed amongst the transducer elements 504 may distort the returnsignal. By positioning the laser aperture 506 to the side or the ends ofthe ultrasound probe 500 without breaking up the transducer elements504, problems may be alleviated or avoided. Thus, the position of thelaser aperture 506 is made outside the ultrasound probe 500 in FIGS.5A-5C to try to minimize interference with the ultrasound signals.

Further description of the transducer elements 504 and their formationinto the ultrasound probe 500 may be found in U.S. Pat. No. 6,088,894entitled METHODS OF MAKING COMPOSITE ULTRASONIC TRANSDUCERS issued onJul. 18, 2000 to inventors Oakley et al., which is incorporated hereinby reference.

Referring now to FIGS. 6A-6B, alternate embodiments of transmission andgeneration of laser energy in the end effector 220 are illustrated. Thelaser cable 302 in the cable bundle 300 may be an optical fiber 302A asshown in FIG. 6A or one or more electrical cables 302B as shown in FIG.6B. In either case, photons of a laser light 600 may exit out from theaperture 506 in the enclosure 502. The position of the aperture 506 inthe end effector is chose to minimize interference to the individualpiezoelectric transducer elements 504 that are stacked in series to formthe ultrasound probe 500.

The end effector 220 may have a lens or a transparent cover 602 mountedand hermetically sealed into the aperture 506. The lens or transparentcover 602 may provide additional collimation or focusing of the laserlight. Alternatively, a separate collimating or focusing lens 604A,604Bmay be provided under the transparent cover 602 to further collimate orfocus the laser light prior to it exiting out from the end effectorthough the aperture 506. The transparent cover 602 and lens 604A,604Bare aligned with the optical axis 610 of the laser light 600.

The transparent cover 602 may be flat-shaped and level with the surfaceof the ultrasound probe enclosure 502 to be cleaned more easily andthoroughly than a curved lens. The transparent cover 602 may be made ofa scratch resistant transparent plastic, fiberglass, glass, crystal, orPlexiglas material suitable for transmitting the wavelength of the laserlight through it. The transparent cover 602 may be hermetically sealedto the enclosure 502 of the end effector to avoid the intrusion ofcontaminants into ultrasound probe 500. With a hermetic seal around thetransparent cover, liquid and gaseous disinfectants that may be used toclean the end effector after surgery is prevented from entering theenclosure 502 and damaging the piezoelectric elements and electricalconnections made therein. If scratched or otherwise damaged thetransparent cover 602 may easier to replace than a curved lens604A,604B.

Light emitted from the distal end 605 of fiber 302A diverges in angle,by an amount determined by the angular spread of the light entering theproximal end of the fiber. In order to couple the laser light into thesmallest possible fiber core, the laser source may use focusing opticsto couple the light, which results in a significant angular divergenceof the entering beam, and therefore of the exiting beam as well. Inaddition, laser light traveling through the insufflating gas used inlaparoscopic surgery may excite the gas and cause it to act as adefocusing lens. When a laser is defocused the diameter of the laser dotincreases without a corresponding increase in the power, thus causing aloss of power density. This blooming effect may cause the laser to charand coagulate instead of cutting tissue as desired. To maintain thehighest possible power density at the outer surface of transparentwindow or cover 602, which with an ultrasound instrument is in contactwith the tissue, a converging lens or lens system may be used,illustrated schematically in FIG. 6A by a single plano-convex lens 604A.

In FIG. 6A, laser energy generated by an external laser generator (e.g.,laser controller generator 102C of FIG. 1A) or a remote internal laserdiode (e.g., laser diode 708 of FIG. 7A) travels down the optical fiber302A and is launched out the end of the optical fiber 302A parallel tothe optical axis 610. The collimating lens 604A may also collimate thelaser light launched out of the end of the optical fiber 302A so it issubstantially parallel to the optical axis 610. The collimated laserlight may exit out of the end effector through the transparent cover 602and onto targeted tissue in a patient's body.

The optical fiber 302A may be a flexible fiber optic cable forcarbon-dioxide (CO2) lasers produced by OMNIGUIDE, for example, if a CO2laser is used in the laser controller/generator.

In FIG. 6B, the end effector 220D includes a laser diode 608 coupled toa printed circuit board (PCB) 609 that is mounted in the housing underthe aperture 506. The one or more electrical cables 302B couple to theprinted circuit board 609 in electrical communication with the laserdiode 608. The active region of the laser diode 608 is centered inalignment with the optical axis 600 under the cover 602 and the lens604B. In this case, the laser energy is locally generated by the tool toease the cable connections to the tool.

The laser diode is excited by power and signals from the electricalcables 302B to generate photons of sufficient energy to exit the activeregion of the laser diode. The photons or laser light from the laserdiode, being somewhat parallel to the optical axis 610 but stilldiverging from the emitting area of the laser diode, is coupled into thelens 604B. The focusing lens 604B may collimate the laser light launchedout of the laser diode so it is substantially parallel to the opticalaxis 610, or focus it at a desired distance from the lens 604B, tocontrol the location along the optical axis 610 where the maximum powerdensity is attained. The collimated laser light may exit out of the endeffector 220D through the transparent cover 602 and onto targeted tissuein a patient's body.

If the laser diode 608 is being used to mark tissue at lower laser powerlevels, cooling the laser diode may be unnecessary. However, if thelaser diode is being used to cut or ablate tissue at higher powerlevels, cooling the laser diode may be useful. If so, a heat sink (notshown) may be thermally coupled to the laser diode to draw heat awayfrom it. Alternatively, a liquid cooling may be provided from anauxiliary channel (not shown) by flowing an irrigating liquid (e.g.,sterile water or saline) pass the laser diode 608 and out of the tool toprovide irrigation in the surgical site and perhaps a backstop to thelaser light. The heat transfer may be by convection or by directlyleaking some of the irrigating liquid around the laser diode avoidingobscuring the surgical site but sufficient to cool the laser.

Referring now to FIG. 7A, the mountable housing 201A of the tool 200A isillustrated with its cover 202A removed to show the internal drivemechanisms and cable connections. The mountable housing 201A includes agimbaled cable actuator 700 to manipulate the cables to control movementof the wristed joint 218. The actuator 700 includes a rocker or actuatorplate 702 mounted in a gimbaled configuration. The actuator plate 702pivotally coupled to a parallel linkage 740. An articulated parallelstrut/ball joint assembly is employed to provide a gimbaled support forthe actuator plate 702. This allows the actuator plate 702 to tilt intwo degrees of freedom.

The proximal ends of the drive cables 216 are coupled to the actuatorplate 702 to control the movement of the wristed joint 218. Apertures onthe actuator plate 702 receive the proximal end of the drive cables 216that extend to the disks or vertebrae of the wristed joint 218.

The actuator 700 further includes a first actuator link 704 and a secondactuator link 706 are rotatably coupled near one end to the actuatorplate 702 through ball joint mechanisms. The actuator plate 702 is movedby the first actuator link 704 and the second actuator link 706 toproduce pitch and yaw rotations in the wristed joint 218.

The actuator 700 further includes a first follower gear quadrant 714 anda second follower gear quadrant 716 pivotally coupled to the mountablebase 204 at pivot points 734 and 736, respectively. The first followergear quadrant 714 is pivotally coupled to the first actuator link 704near its second end by a pivot joint 718. The second follower gearquadrant 716 is pivotally coupled to the second actuator link 706 nearits second end by a pivot joint 720.

The actuator 700 further includes a first drive gear 724 and a seconddrive gear 726 geared to the first follower gear quadrant 714 and asecond follower gear quadrant 716. Each of the first drive gear 724 andthe second drive gear 726 are coupled to a first end of a rotatabledrive shaft 740 extending through the mountable base 204. A rotatablereceiver 742 is coupled to the opposite end of each rotatable driveshaft 740. Each rotatable receiver 742 of the tool mates with arotatable driver of the robotic surgical arm when mounted thereto.

As the rotatable receivers 742 are driven by a rotatable driver of therobotic surgical arm, the drive gears 724,726 rotate to respectivelypivot the first and second follower gear quadrants 714, 716 about theirrespective pivot points 734,736. As the first and second follower gearquadrants 714, 716 rotate about their respective pivot points 734,736,the actuator links 704, 706 coupled by the joints 718,720 to the gearquadrants are driven to generally move longitudinally and pivot theactuator plate 702 and move the drive cables 216.

FIG. 7A illustrates the actuator plate 702 of the gimbaled cableactuator 700 in a pitch rotation by both actuator links 704, 706 movingtogether in parallel. A mixture of pitch and yaw rotations in theactuator plate 700 is the result of mixed movement in the actuator links704, 706 in response to the corresponding rotation of the rotatablereceivers 742, rotatable drive shafts 740, and gears 724,726.

The cable actuator 700 is described in further detail in U.S. Pat. No.6,817,974 entitled SURGICAL TOOL HAVING POSITIVELY POSITIONABLETENDON-ACTUATED MULTI-DISK WRIST JOINT filed by Thomas G. Cooper et al.on Jun. 28, 2002, which is incorporated herein by reference.

However, alternative embodiments of the pivoted-plate cable actuatormechanism having aspects of the invention may have different structuresand arrangements for supporting and controllably moving the actuatorplate 702. For example the plate may be supported and moved by varioustypes of mechanisms and articulated linkages to permit at least tiltingmotion in two DOF, for example a Stewart platform and the like. Theplate assembly may be controllably actuated by a variety of alternativedrive mechanisms, such as motor-driven linkages, hydraulic actuators;electromechanical actuators, linear motors, magnetically coupled drivesand the like.

In one embodiment of the invention, an optical fiber 302A is routed fromthe aperture 506 at the end effector through the tool 200A into thecable 106 to the connector 210A as shown in FIGS. 2A, 3, 4, 5A, 6A, and7A. In this case, an external laser generator/controller (e.g., lasergenerator/controller 102A of FIG. 1A) is used to generate the laserlight.

In another embodiment of the invention, an optical fiber 302A is routedfrom the aperture 506 at the end effector 202 through the shaft 214 andto a laser diode 708 coupled to a printed circuit board 709 mounted inthe housing 201A. An end of electrical laser cables 302B′ are coupled tothe printed circuit board 709 in communication with the laser diode 708.The electrical laser cables 302B′ are routed in the laser cable 106 andcouple to the connector 210A. Instead of generating the laser light, thelaser generator/controller 102A generates control signals in theelectrical laser cables 302B′ to control the local generation of laserlight by the laser diode 708. The laser light generated by the laserdiode 708 is coupled into the optical fiber 302A′ to route the laserlight through the tool to the aperture 506 in the end effector 220.

Referring now to FIG. 2B, an alternate embodiment of a combined laserimaging tool 200B is illustrated. The combined laser imaging tool 200Bis similar to the combined laser imaging tool 200A but generally differsin the mountable housing 201B and how a laser cable 106 and anultrasound cable 108 couple there-to. The laser cable 106 provides ameans for routing signals from a laser generator/controller to therobotic surgical tool 200B. The ultrasound cable 108 provides a meansfor routing signals from an ultrasound generator/controller to therobotic surgical tool 200B. With the combined laser imaging tool 200B,the laser cable 106 and the ultrasound cable 108 are readily detachablefrom the tool. This may be advantageous to ease sterilizing the tool orto more quickly make equipment changes.

Referring for the moment to FIG. 2A, a first laser cable connector 210Ais coupled to a first end of the laser cable 106 as shown. The firstconnector 210A is used to connect the laser cable 106 to a lasergenerator/controller. Referring now to back FIG. 2B, a second lasercable connector 210B is coupled to the second end of the laser cable106. To connect the laser cable 106 to the tool 200B, the secondconnector 210B quickly couples to a laser cable receptacle 226. Thesecond connector 210B may also be quickly detached from the receptacle226. The first and second connectors 210A-210B may be male bayonetNeill-Concelman (BNC) connectors and the receptacle 226 may be a femaleBNC connector. If a surgeon decides a different robotic surgical tool isneeded in place of the tool 200B, the cable 106 can be quickly detachedto more quickly make a tool change.

Referring for the moment to FIG. 2A, a first ultrasound connector 212 iscoupled to a first end of the ultrasound cable 108 as shown. The firstconnector 212 is used to connect the ultrasound cable 108 to anultrasound generator/controller. Referring now to back FIG. 2B, a secondultrasound connector 222 is coupled to the second end of the ultrasoundcable 108. To connect the ultrasound cable 108 to the tool 200B, thesecond connector 222 quickly couples to an ultrasound receptacle 224.The connector 222 may be a male electrical pin connector while thereceptacle 224 is a female electrical pin connector. The secondconnector 222 may be quickly detached from the receptacle 224. If asurgeon decides a different robotic surgical tool is needed in place ofthe tool 200B, the cable 108 can be quickly detached to more quicklymake the tool change.

The ultrasound wires 304 coupled to the ultrasound transducers 504 maycouple to the receptacle 224. However, with the electrical connector 222and receptacle 224, the pin and wire count in the ultrasound cable 108may be reduced to avoid large pin counts and avoid routing so many wiresbetween connectors 212 and 222. In this case, a plurality of ultrasoundsignals may be serialized or multiplexed onto one signal wire of theultrasound cable 108.

Referring now to FIG. 7B, the mountable housing 201B of the tool 200B isillustrated with its cover 202B removed to show the internal drivemechanisms and cable connections. The mountable housing 201B is similarto the mountable housing 201A but for how the laser cable 106 and theultrasound cable 108 are coupled there-to.

The mountable housing 201B includes the gimbaled cable actuator 700previously described herein to manipulate the driver cables 216 tocontrol movement of the wristed joint 218. The description of thegimbaled cable actuator 700 is incorporated here by reference to avoidduplicity.

The mountable housing 201B further includes the ultrasound cablereceptacle 224 and the laser cable receptacle 226 mounted to the base204 and/or the cover 202B. The mountable housing 201B may furtherinclude an isolation chamber 203B under the cover 202B to isolate aprinted circuit board 750, the electrical connections, and electricalcables from the drive mechanisms or transmission for the drive cables216.

As previously mentioned, a plurality of ultrasound signals may beserialized or multiplexed onto one signal wire of the ultrasound cable108. The ultrasound connector 222 couples to the ultrasound receptacle224 to couple power/signal wires of the ultrasound cable 108 to thepower/signal wires 756. The power/signal wires 756 couple to the printedcircuit board 750. The printed circuit board 750 includes an ultrasoundsignal combiner 752 and an ultrasound voltage generator 754 coupledtogether. The signal wires couple to the ultrasound signal combiner 752.The power wires couple to the ultrasound voltage generator 754.

The signal combiner acts as a multiplexer/demultiplexer and/orserializer/deserializer to combine a plurality of signals from theultrasound sensors together for communication over fewer parallel wiresto the external ultrasound generator/controller. This allows the pincount of the ultrasound connector 222 and the ultrasound receptacle 224to be less so they are smaller connectors. Additionally, there are fewerwires routed in the ultrasound cable 108.

An end of the ultrasound signal wires 304 are coupled to the printedcircuit board 750 and the signal combiner 752 and/or voltage generator754. The ultrasound signal wires 304, as part of the cable bundle 300,are routed through a center opening in the actuator plate 702, through ahollow center of the parallel linkage 740, and into the shaft 214 of thetool.

The ultrasound transducers 504 are excited by high voltages to generateultrasound signals. Instead of generating high voltage signals at anexternal ultrasound generator/controller, it may be more convenient tolocally generate the high voltage signals to excite the ultrasoundtransducers 504. In response to control signals from the signal combiner752, the ultrasound voltage generator 754 generates a plurality of highvoltage signals for exciting the ultrasound transducers 504 to generatethe ultrasound signals.

The laser cable receptacle 226 couples to an end of the laser cable 302.The laser cable 302 may be an optical fiber 302A to propagate laserlight to the end effector 220A or electrical control wires 302B to powerand signal a laser diode 608 in the end effector 220D. In either case,the laser cable 302, as part of the cable bundle 300, is routed throughthe center opening in the actuator plate 702, through the hollow centerof the parallel linkage 740, and into the shaft 214 of the tool forrouting to the end effector.

If the laser cable 302 is an optical fiber 302A, the use of theconnector 210B and the receptacle 226 may allow it to be readilyreplaced if damaged or defective to repair the tool. Optical fibers aresusceptible to heat damage from excess laser energy as well shock damagefrom misuse. Optical fibers may also acquire microscopic cracks orbreaks if they exceed their maximum radial bend. Once heat damaged orcracked, the optical fiber may not transmit laser energy as efficiently,resulting in decreased laser energy at the working end. If the lasercable 106 is damaged or defective, the use of the connector 210B and thereceptacle 226 may allow it to be readily replaced if damaged ordefective.

Operation of the Combined Ultrasound-Laser Tool

Referring now to FIG. 8, an illustration depicts an image 800 of thesurgical site and the ultrasound picture in picture images that may bedisplayed in the viewer of the surgeon's console. A two-dimensional orthree-dimensional image is displayed on a video screen for the surgeonperforming the procedure. Ultrasound images 811B-811D are combined andinterpolated by a computer processor into a combined ultrasound image811A. A targeting dot 822 may be displayed on combined ultrasound image811A to represent the location where the laser is focused. In oneembodiment of the invention, the targeting dot 822 is acomputer-generated dot (such as generated by the computer 151A, 151B)that appears only on the display monitor and is not a physical mark inthe surgical site.

The targeting dot 822 may be used by the surgeon to aim the markinglaser in an ultrasound image. For instance, as mentioned previously,ultrasounds may be used to differentiate healthy cells from cancerouscells. Once masses of cancerous cells are identified on the ultrasoundimage, a surgeon may begin marking the boundaries of the cancerous cellsfor later removal. A marking laser may be used to burn a series of dotsdelineating the boundaries of the cancerous mass. The burn marks wouldnot likely show up on an ultrasound image, so in order to aid thesurgeon, a virtual display of the burn marks may be created with somespecialized software. Each time the laser is fired a virtual dot may bedisplayed on the video monitor. In this way, the surgeon may be betterable to track their progress as they mark the area to be excised. Oncethe area is marked, the ultrasound images may be removed from the videomonitor displaying video images of the surgical site. The burn marksshould be optically visible by the camera and shown in the video displayto provide the surgeon with an accurate map of the area to be excised.

In another embodiment of the invention, a cutting laser such as a CO2laser may be deployed at the ultrasound probe. Once again, the targetingdot 822 may be used by the surgeon to guide the laser cutter. A virtualimage of the cut line may be created by software and superimposed onultrasound image 811A to aid the surgeon in guiding the laser.

Referring now to FIG. 9, an image of the surgical site 900 isillustrated after laser marking has been completed. The dotted line 902represents burn marks made on tissue by a laser that was guided byultrasound imagery. The laser marked tissue can reduce the time spentlooking for tissue that requires surgery. Robotic surgical tools 910Land 910R, such as robotic surgical scissors, may be readily moved intothe marked area to perform surgery therein.

The added functionality provided by a combined laser/imaging tool mayimprove the efficiency of a surgeon and thereby lower the costs ofminimally invasive surgical procedures. With a four arm robotic surgicalsystem or the like, an endoscopic camera tool and an ultrasound imagingtool with lasers are available while a surgeon performs surgery with hisleft and right hands controlling tissue manipulative robotic surgicaltools (e.g., monopolar scissor, and a bipolar grasper). With thelaser/ultrasound combination, a surgeon may have three types of energy(monopolar, bipolar, and laser) to apply to tissue, two imagingcapabilities (camera and ultrasound, with picture in picture) and twomechanical tools (cutting and grasping) for combined seven tools usingonly four robotic surgical arms.

Robotically Controlled Endoscopic Camera with Laser Cutting Tool

To perform minimally invasive surgery in areas around the neck andthroat, a robotic surgical system that can use the openings provided bythe nose or throat may be preferable. However, this limits the number ofopenings through which robotic surgical tools may be inserted. Therobotic surgical tools are made smaller so that a plurality of roboticsurgical tools may pass through a single opening. To gain even moresurgical capability through the one opening, the robotic surgical toolsmay be multitasking in their capabilities.

Previously described herein was a combined ultrasound-laser roboticsurgical tool. A combined laser-endoscopic camera robotic surgical toolis now described to provide multiple surgical capabilities in onerobotic surgical tool.

Referring now to FIG. 10, a portion of a patient side cart 1052 isillustrated with an actuating end 1016 of a robotic or manipulating arm1014. But for a single robotic arm 1014, other portions of the patientside cart 1052 may be similar to the patient side cart 252 illustratedin FIG. 1B to support the actuating end 1016 over a patient P. Therobotic arm 1014 may be coupled to a set-up arm. The robotic surgicalsystem including the patient side cart 1052 may be similar to therobotic surgical systems illustrated in FIGS. 1A and 1C including theone or more control consoles and the laser/generator controller.

The general function of the actuating end 1016 of the robotic ormanipulating arm 1014 and the robotic surgical tools coupled thereto aredescribed in more detail in U.S. patent application Ser. No. 11/762,165entitled MINIMALLY INVASIVE SURGICAL SYSTEM filed by Larkin et al. onJun. 12, 2007 which is incorporated herein by reference.

A single guide tube 1008 of the actuating end 1016 of the robotic arm isused to insert the tools 1002A, 1002B, and 1018 into an opening into thepatient P, such as the patient's mouth for example. The guide tube 1008is coupled to the platform 1012 which is in turn moveably coupled to therobotic arm 1014 by one or more actuator mechanisms for pitch, yaw,roll, and insertion along an insertion axis of the guide tube. The guidetube 1008 may be maintained in a fixed position or rotated (e.g., pitch,yaw, and/or roll) around a remote center point 1020 near the openinginto the patient if permitted by the circumstances, including the tissuein the body where the tools may be located.

The robotic surgical tool 1018 that is more fully inserted into theguide tube 1008 is a combined laser ablation-imaging robotic surgicaltool to provide multiple capabilities in one instrument. The two otherrobotic surgical tools 1002A-1002B are illustrated as being partiallyinserted into the guide tube 1008 in FIG. 10. The robotic surgical tools1002A-1002B may be different types of robotic surgical tools than thecombined laser ablation-imaging robotic surgical tool 1018. The combinedlaser ablation-imaging robotic surgical tool 1018 efficiently uses theavailable opening provided by the singular guide tube 1008.

Referring now to FIG. 11, a proximal end of the robotic surgical tools1018, 1002A-1002B are shown inserted into the guide tube 1008 andcoupled to a tool actuator assembly 1004. Each tool 1018, 1002A, 1002Bmay include a body tube 1006 inserted into the guide tube 1008. The toolactuator assembly 1004 is mounted to a linear actuator 1010 (e.g., aservo-controlled lead screw and nut, or a ball screw and nut assembly)that independently controls each tool's further insertion within guidetube 1008 along with its body tube's 1006. The guide tube 1008 may beremoveably mounted to the support platform 1012. Removable andreplaceable guide tubes allow different guide tubes designed for usewith different procedures to be used with the same telemanipulativesystem (e.g., guide tubes with different cross-sectional shapes orvarious numbers and shapes of working and auxiliary channels).

The actuator assembly 1004 mates with and actuates components in therobotic surgical tools 1018, 1002A-1002B. The actuator assembly 1004includes a plurality of rotatable servomotor actuators 1126 coupled toactuator disks 1122. Each actuator disk 1122 includes holes to interfaceto pins of rotatable interface disks of the robotic surgical tools. Eachactuator disk 1122 is rotated in response to servo control inputs tocontrol the robotic surgical tool.

Referring now to FIG. 12, a distal end of the robotic surgical tools1018, 1002A-1002B is shown extending out from the guide tube 1008. Theguide tube 1008 includes a channel 1218 and a pair of channels 1202through which the respective robotic surgical tools 1018 and 1002A-1002Bmay be inserted and extend. The guide tube 1008 may further include anauxiliary channel 1260 through which other robotic surgical tools may beintroduced or withdrawn, such as irrigation, suction, or cleaningdevices for example. As illustrated in FIG. 12, the body tube 1006 ofeach respective robotic surgical tool 1018, 1002A-1002B may extend outfrom the respective channels of the guide tube 1008. With for the guidetube 1008 entering natural orifices of a body, its diameter and thediameter of each respective robotic surgical tool 1018, 1002A-1002B islimited. By providing more than one capability to a robotic surgicaltool, the limited diameter of the guide tube is more efficientlyutilized. Moreover, a tool change may be reduced or eliminated bycombining more than one capability into a robotic surgical tool.

Each of the respective robotic surgical tools 1002A-1002B include endeffectors 1248A-1248B coupled to the body tube 1006 by one or morejoints 1244A-1244B, 1246A-1246B, and a parallel tube 1245A-1245B. In oneinstance, the body tube 1006 for the robotic surgical tools 1002A-1002Bis approximately 7 mm in diameter. In another instance, the body tube1006 for the robotic surgical tools 1002A-1002B is approximately 5 mm indiameter.

The combined laser ablation-imaging robotic surgical tool 1018 is nowdescribed in more detail.

Referring now to FIG. 13, a perspective view of the combined laserablation-imaging robotic surgical tool 1018 is illustrated. The combinedlaser ablation-imaging robotic surgical tool 1018 includes a housing1301 with a mountable base 1304, a transmission mechanism 1303, a shaftor body tube 1006, and an end effector 1348 coupled together. Thehousing 1301 and the transmission mechanism 1303 are coupled to theproximal end of the body tube 1006 while the end effector 1348 iscoupled to the distal end of the body tube 1006. The end effectors 1348may couple to the body tube 1006 by one or more joints 1344, 1346, and aparallel tube 1345. The one or more joints may be wristed joints, suchas the segmented wristed joint described previously with reference toFIG. 4. The shaft or body tube 1006 for the combined laserablation-imaging robotic surgical tool 1018 may or may not becylindrically shaped.

The transmission mechanism 1303 provides a mechanical interface for thetool and includes a plurality of rotatable interface disks 1310. One ormore the rotatable interface disks 1310 are associated with a degree offreedom of the combined laser ablation-imaging robotic surgical tool1018. For example, a rotatable interface disk 1310 may be associatedwith instrument body roll degree of freedom illustrated by thedoubled-headed arrow 1316. The rotatable interface disks 1310 may bearranged for compactness, such as the triangular shape as shown forexample. Each rotatable interface disk 1310 includes a pair of spacedapart raised pins 1312. The raised pins 1312 of each rotatable interfacedisk may be spaced eccentrically to provide proper disk orientation whenmated with an associated actuator disk.

The transmission mechanism 1303 includes a plurality of mechanicalcomponents (e.g., gears, levers, gimbals, cables, etc.) to convert rolltorques 1320 received by the rotatable interface disks 1310 and transmitthe torque into movement of the components of the combined laserablation-imaging robotic surgical tool 1018, such as roll 1316 in thebody tube 1006 or pitch in the end effector 1348, for example. One ormore cables, cable loops, hypotubes, and/or any combination thereofwithin the body tube may be used to transfer the torque received by thetransmission mechanism 1303 to the components at the distal end of thetool, such as the pitch movement of the end effector 1348.

The housing 1301 includes one or more electronic interface connectors1314 to provide an electronic interface for the combined laserablation-imaging robotic surgical tool 1018. One or more of theelectronic interface connectors 1314 are used to interface to one ormore cameras in the end effector 1348.

One or more of the electronic interface connectors 1314 may be used topass information stored in a semiconductor memory integrated circuit tothe master control console regarding the tool and its end effectors.Such passed information may include instrument type identification,number of instrument uses, and the like. The control system may used toupdate the stored information (e.g., to record number of uses todetermine routine maintenance scheduling or to prevent using aninstrument after a prescribed number of times).

One or more of the electronic interface connectors 1314 may be used toconnect to a power supply or a laser generator to provide power forelectronics in the tool, such as a laser diode. Alternately, a powerconnection may be positioned elsewhere in the housing 1301 on the tool1018. Other connectors for, e.g., optical fiber lasers, optical fiberdistal bend or force sensors, irrigation, suction, etc. may be part ofthe housing 1301.

One or more of the electronic interface connectors 1314 may also be usedto interface to a laser diode in the end effector 1348 in one embodimentof the invention. The electronic interface connector 1314 can coupleelectrical cables together so that the laser diode can couple to a lasercontroller 102B to control the laser diode.

In another embodiment of the invention, the housing may include areceptacle 226, such as a BNC receptacle 226, coupled to a fiber opticcable leading to an end of the end effector 1348. A BNC connector 210connects to the BNC receptacle 226 to couple fiber optic cables togetherto route laser energy from a laser generator 102B into a fiber opticcable 1326 within the tool. The fiber optic cable 1326 routes thereceived laser energy through the tool to the end of the end effector1348. Depending upon the life expectancy of the overall tool and fiberoptic cable 1326 used for lasing, the cable 1326 may be readilyreplaceable. If the expected life expectancy of the fiber optic cable1326 exceeds that of the overall tool, the cable 1326 may not need to beeasily replaceable and be more integrated into the tool to lower costs.On the other hand, if the expected life expectancy of the fiber opticcable 1326 were only one surgery, it would be designed to be readilyreplaceable. Other fiber optic cables (see FIGS. 14A-15A) may be used totransmit lower light energy to provide lighting within a body cavity forthe one or more cameras in the tool 1018 to capture video images.

End Effector for Image Capture and Laser Cutting

FIGS. 14A-14B and 15A-15B respectively illustrate alternate embodimentsof the end effector 1348 (end effectors 1348A, 1348B) of the combinedlaser ablation-imaging robotic surgical tool 1018.

Referring now to FIG. 14A-15A, the combined laser ablation-imagingrobotic surgical tool 1018 includes a fiber optic bundle 1400terminating at the end effector 1348A, and one or more cameras1402A-1402B. The fiber optic bundler 1400 includes the fiber optic cable1326 within a channel 1426, and a plurality of light pipes or fiberoptic cables 1436 bundled together around the channel 1426 by a sheath1446. Alternatively, the plurality of light pipes or fiber optic cables1436 may be bundled together and routed through separate channels withinthe tool 1018. Light for the plurality of light pipes or fiber opticcables 1436 may be generated by one or more light emitting diodes (LED)in the tool such as to the diode 708 illustrated in FIG. 7A, oralternatively generated by an external illuminator such as a Xenonshort-arc lamp, or by other well-known means. Alternatively, one or morelight emitting diodes (LED) may be included as part of the end effector,space permitting, instead of the using the plurality of light pipes orfiber optic cables 1436.

The fiber optic cable 1326 can carry sufficient laser energy from thelaser generator 102B to laser cut or ablate tissue. The laser energyfrom the laser generator 102B, transmitted in the fiber optic cable 1326and coupled to tissue, may be less in order to mark the tissue in thebody. That is, the laser energy may be selected for laser marking oftissue. A focusing lens or lens system 1427A may be located between thedistal end of the fiber optic cable 1326 and the inside surface of thetransparent cover or window 1481A, and functions to collimate the laserlight diverging from the fiber optic cable 1326, or to focus it in orderto attain maximum energy density at a desired distance from the externalsurface of the transparent cover or window 1481A. The channel 1426 mayfacilitate the replacement of the fiber optic cable 1326 if the needarises. The number of light pipes or fiber optic cables 1436 in the tool1018 is such that if a couple fail, the lighting supplied by those stillfunctioning is sufficient for the one or more cameras to continuecapturing images. The cameras sensitivity may also be able to compensatefor some loss of lighting due to the failed light pipes or fiber opticcables 1436.

The one or more cameras 1402A-1402B each include an image sensor 1451(e.g., charge coupled device array), one or more lenses 1452A-1452B, anda transparent cover 1461 aligned together along an optical axis 1460 bya housing 1462. The image sensor 1451 captures images from light passingthrough the transparent cover. The one or more lenses 1452A-1452Bcapture light from the objects in the surgical field, and focus it intothe image sensor 1451. The transparent cover 1461 may be hermeticallysealed to the camera housing 1462 and/or the end effector enclosure1465.

Each of the one or more cameras 1402A-1402B may further include a filter1454 aligned to the optical axis 1460 by the housing 1462 before thelight rays reach the image sensor 1451. The filter 1454 may be used tofilter out excessive light generated by the laser generator for lasercutting. The filter 1454 may be particularly tuned to filter out thewavelength of light used for laser cutting while allowing lights ofother wavelengths to pass through into the image sensor 1451. Forexample, the laser may be chosen to emit a 532 nm wavelength (greenlaser light) over a power range of about 25-60 watts. To avoid the laserlight from saturating the image sensor 1451 in each video camera1402A-1402B, the filter 1454 may be tuned to filter out green lightaround a wavelength of 532 nanometers.

An electrical cable 1466 may be coupled to the image sensor 1451 of eachof the one or more cameras 1402A-1402B to provide power to the imagesensor 1451 and transfer digital data of the captured images through thetool 1018 to the control consoles 150A-150B. One of the one or moreelectronic interface connectors 1314 may couple to the electrical cables1466 to facilitate the removal and replacement of the combined laserablation-imaging robotic surgical tool 1018.

Referring now to FIG. 15A, the end effector 1348A may include one ormore alignment tabs 1502A-1502B as part of the enclosure 1465. The oneor more alignment tabs may extend along the body of the tool 1018 sothat the one or more cameras and each image sensor 1451 is retained inalignment with the end effector 1348 and its controlled movement.

Referring now to FIGS. 14B-15B and the end effector 1348B, the combinedlaser ablation-imaging robotic surgical tool 1018 at its distal endincludes the one or more cameras 1402A-1402B and a laser diode 1480instead of the fiber optic cable. The plurality of light pipes or fiberoptic cables 1436 are bundled together into one or more channels 1490 asillustrated in FIG. 15B to provide lighting for the one or more cameras1402A-1402B. A transparent cover may be hermetically sealed to theenclosure 1465 over the end of the plurality of light pipes or fiberoptic cables 1436 to avoid body fluids from seeping into the endeffector so that the tool can be readily sterilized. Light for theplurality of light pipes or fiber optic cables 1436 may be generated byone or more light emitting diodes (LED) in the tool such as to the diode708 illustrated in FIG. 7A, or alternatively generated by an externalilluminator such as a Xenon short-arc lamp, or by other well-knownmeans. Alternatively, one or more light emitting diodes (LED) may beincluded as part of the end effector, space permitting, instead of theusing the plurality of light pipes or fiber optic cables 1436.

As shown in FIG. 14B, the laser diode 1480 is coupled to one end of anelectrical cable 1486 to provide power and to control the generation ofthe laser light along an optical axis 1482. Another end of theelectrical cable 1486 is coupled to one or more of the electronicinterface connectors 1314 of the tool 1018 to couple to a lasercontroller, such as the laser controller/generator 102B illustrated inFIGS. 1A, 1C.

From the laser diode 1480, laser light passes through a transparentcover or window 1481B and out of the tool into a body cavity. Thetransparent cover 1481B may be hermetically sealed to the enclosure 1465of the end effector 1348B to avoid body fluids from seeping into the endeffector so that the tool can be readily sterilized. A focusing lens orlens system 1427B may be located between the active region of the laserdiode 1480 and the inside surface of the transparent cover or window1481B, and functions to collimate and or focus the laser light divergingfrom the active region of the laser diode, or to focus it in order toattain maximum energy density at a desired distance from the externalsurface of the transparent cover or window 1481B.

When lasing, the laser diode 1480 may generate heat. The laser diode1480 may be coupled to a heat removal device 1484, such as a passiveheat sink or slug. Additionally or alternatively, a fluid channel 1492may be routed through the tool 1018 adjacent the laser diode 1480 totransfer heat away from it. The fluid may also flow through the channeland out of the tool 1018 into a body cavity to irrigate it. If thechannel is under suction, fluid may flow out of the body cavity into thechannel 1492, along the laser diode 1480 to cool it, and out of the tool1018. If the laser diode 1480 is of sufficiently low power, liquidcooling by a fluid channel may be unnecessary.

A similar fluid channel may be made available in the combinedlaser-ultrasound tool to cool down a heated ultrasound probe. However,as the ultrasound tool may be in front of the combined laser-cameratool, the fluid channel 1492 of the combined laser-camera tool or adedicated suction/irrigation tool may be used to douse the ultrasoundprobe with a cool liquid to remove heat there-from.

Referring now to FIG. 9, the combined laser-endoscopic camera tool 1018captures images of a surgical site for display in the viewer of thesurgeon's console. A bulls eye 920 may be computer generated andoverlaid onto the images of the surgical site for display in the viewer.The bulls eye 920 may indicate the point where the laser can mark or cuttissue within the field of view of the surgical site. As an endoscopiccamera is usually used to capture images of a surgical site, combing thelaser with the camera provides an additional tool that a surgeon may useto cut tissue without using additional cannulas or ports of entry intothe surgical site.

Moreover, with reference to FIGS. 1D and 9, one surgeon O operating at afirst console 150A may be manipulating the tools 910L, 910R within thesurgical site 900 while another surgeon M may be operating the laser ofthe combined laser-endoscopic camera tool 1018 at a second console 150B.The second surgeon operating the combined laser-endoscopic camera toolmay help reduce the time spent performing a minimally invasive surgery.

CONCLUSION

While this specification includes many specifics, these should not beconstrued as limitations on the scope of the disclosure or of what maybe claimed, but rather as descriptions of features specific toparticular implementations of the disclosure. Certain features that aredescribed in this specification in the context of separateimplementations may also be implemented in combination in a singleimplementation. Conversely, various features that are described in thecontext of a single implementation may also be implemented in multipleimplementations, separately or in sub-combination. Moreover, althoughfeatures may be described above as acting in certain combinations andeven initially claimed as such, one or more features from a claimedcombination may in some cases be excised from the combination, and theclaimed combination may be directed to a sub-combination or variationsof a sub-combination. The claimed invention is limited only by patentedclaims that follow below.

What is claimed is:
 1. A robotic surgical system comprising a displaydevice; an endoscopic surgical tool including a mountable housing havinga base and at least a first actuator and a second actuator mounted tothe base, the base adapted to mount to a robotic surgical arm to actuatethe first actuator and the second actuator; a hollow shaft having afirst end rotatably coupled to the mountable base, the hollow shaft toextend into a surgical site and rotate in response to the firstactuator; a wristed joint having a first end coupled to a second end ofthe hollow shaft, a second end of the wristed joint to move in responseto the second actuator; and an end effector coupled to the second end ofthe wristed joint to concurrently move with the second end of thewristed joint, the end effector including a hermetically sealedenclosure having an aperture with a transparent cover hermeticallysealing over the aperture, a laser-emitting device mounted in theenclosure near the aperture, the laser-emitting device configured toemit laser light out to the surgical site through the aperture, and anultrasound probe mounted in the enclosure, the ultrasound probeconfigured to capture ultrasound images of a surgical site; a computergenerated targeting dot displayed on the display device; and one or moreprocessors configured to control the ultrasound probe, thelaser-emitting device, and the display device, the one or moreprocessors further configured to generate the computer generatedtargeting dot at a location where the laser-light is focused.
 2. Therobotic surgical system of claim 1, wherein the ultrasound probeincludes one or more arrays of piezo-electric elements mounted in theenclosure.
 3. The robotic surgical system of claim 2, wherein thelaser-emitting device comprises an optical fiber having a first end withan optical axis aligned with the aperture to emit the laser light fromthe end effector.
 4. The robotic surgical system of claim 1, furthercomprising: an imaging cable coupled to the mountable housing having afirst end routed through the shaft and coupled to the ultrasound probe;and a laser cable coupled to the mountable housing to control theemission of the laser light by the laser-emitting device.
 5. The roboticsurgical system of claim 4, wherein the laser emitting device comprisesan optical fiber, the optical fiber routed through the tool and thelaser cable having a first end with an optical axis aligned with theaperture to emit the laser light and a second end coupled to a connectorto couple to a laser generator.
 6. The robotic surgical system of claim4, wherein the laser emitting device comprises a laser diode to generatethe laser light, the laser diode mounted in the enclosure with anoptical axis aligned with the aperture to emit the laser light, and thelaser cable is an electrical cable routed through the shaft and coupledto the laser diode to control the generation of the laser light.
 7. Therobotic surgical system of claim 4, wherein the laser emitting devicecomprises a laser diode mounted in the mountable housing to generate thelaser light and an optical fiber routed through the shaft to propagatethe laser light to the aperture, the optical fiber having a first endwith an optical axis aligned with the aperture to emit the laser lightand a second end aligned with an optical axis of the laser diode toreceive the laser light, and the laser cable is an electrical cablecoupled to the laser diode mounted in the mountable housing to controlthe generation of the laser light.
 8. The robotic surgical system ofclaim 1, further comprising: an imaging cable receptacle mounted in themountable housing to couple to an imaging cable connector of an externalimaging cable, an internal imaging cable having a first end coupled tothe imaging cable receptacle, the internal imaging cable routed throughthe shaft and having a second end coupled to the ultrasound probe; alaser cable receptacle mounted in the mountable housing to couple to alaser cable connector of an external laser cable; and an internal lasercable having a first end coupled to the laser cable receptacle, theinternal laser cable routed through the shaft and having a second endpositioned near the aperture.
 9. The robotic surgical system of claim 1,wherein the end effector further includes a transparent cover mounted inthe aperture to seal the enclosure, the transparent cover beingtransparent to the laser light to allow it to pass through; and a lensmounted in the enclosure between the laser emitting device and thetransparent cover in alignment with the optical axis, the lens tocollimate or focus the laser light out through the transparent cover.10. A robotic surgical system comprising: a combined laser ultrasoundimaging surgical tool mounted to a first robotic arm of a patient sidecart, the combined laser ultrasound imaging surgical tool having awristed joint and an end effector coupled to the wristed joint, the endeffector having a laser emitting device to direct a laser beam ontotissue in a surgical site and an ultrasound image capturing device tocapture ultrasound images of the tissue in the surgical site, the laseremitting device and the ultrasound image capture device mounted in ahermetically sealed enclosure with an aperture; a first control consolein communication with the combined laser ultrasound imaging surgicaltool to receive the captured ultrasound images of tissue in the surgicalsite, the first control console to display the captured ultrasoundimages on a first display device to a first user and one or moreprocessors within the first control console configured to generate acomputer generated targeting dot overlaid on the captured ultrasoundimages, the computer generated targeting dot representing a locationwhere the laser beam from the laser emitting device is focused; and alaser generator/controller coupled to the combined laser ultrasoundimaging surgical tool and the first control console, the lasercontroller/generator to control the emission of the laser beam ontotissue of the surgical site by the combined laser ultrasound imagingsurgical tool in response to a control signal.
 11. The robotic surgicalsystem of claim 10, further comprising: an ultrasoundgenerator/controller coupled to the first control console and thecombined laser ultrasound imaging surgical tool, the ultrasoundgenerator/controller to generate ultrasound signals to excite anultrasound probe to emit ultrasound waves onto the tissue in thesurgical cite, the ultrasound probe to capture return ultrasound wavesto generate received signals, the ultrasound generator/controller totranslate the received signals into the ultrasound images for display onthe first display device.
 12. The robotic surgical system of claim 11,further comprising: an endoscopic camera coupled to a second robotic armof the patient side cart and the first control console, the endoscopiccamera to capture video images of the surgical site and communicate thecaptured video images to the first control console; and wherein thecaptured video images are displayed on the first display device and thecaptured ultrasound images are displayed picture-in-picture on the firstdisplay device.
 13. The robotic surgical system of claim 12, wherein theendoscopic camera is a stereo video camera and the captured video imagesare stereo video images of the surgical site.
 14. The robotic surgicalsystem of claim 10, further comprising: a second control console incommunication with the combined laser ultrasound imaging surgical toolto receive the captured ultrasound images of tissue in the surgical siteand display the captured ultrasound images on a second display device toa second user; wherein the first user to generate control signals tocontrol the laser generator/controller and the combined laser ultrasoundimaging surgical tool to position and emit the laser light to marktissue such that it is visible to a video camera; and wherein the secondcontrol console is in communication with a second surgical tool coupledto a second robotic surgical arm and a third surgical tool coupled to athird robotic surgical arm of the patient side cart, and the second userto perform surgery on the tissue in the surgical site in response to themarked tissue.